Health care wonks turn to 2016

Even before the midterm election that’s likely to turn heavily on Obamacare, health care wonks from both parties are already thinking ahead, taking the first early cracks at health care ideas the next White House candidates can use.

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But the challenges will be starkly different for the two parties. For the Democratic candidates — whether it’s Hillary Clinton or anybody else — the question isn’t whether they should support the Affordable Care Act. It’s an article of faith that they will. Instead, they’ll have to develop their own, distinctive health care agenda that builds on it, by laying out the next steps in health care reform and recommending fixes to the law’s problems, according to Democratic health care experts.

“Someone like Clinton is going to say, ‘I’m going to keep the structure of the ACA, and I’m going to improve it in these ways, and I’m going to move forward,’” said John McDonough, a former adviser to Sen. Ted Kennedy who worked on the health care law.

For the Republican candidates, all signs suggest that they’ll still run on repealing the law, because that will be a basic demand from their supporters. By 2016, though, they’ll have to say what to do about the people who are already getting coverage from Obamacare. And it won’t just be 8 million — there will be two more enrollment seasons, and there could be millions more people who have signed up for benefits.

So any serious Republican candidate can’t just run on repeal, according to GOP health care experts. They’ll have to have not just a replacement plan, but a plausible way to move those millions of people to new coverage without losing their benefits.

“Of course, you’re going to have to build in a transition so people aren’t abruptly uprooted,” said James Capretta, a health care expert at the Ethics and Public Policy Center who has suggested possible GOP alternatives. But “you start with repeal,” he said, because “there’s just so much wrong with the existing law.”

Right now, the policy thinking is at its earliest stages. And Republicans are spending more time on it than Democrats, who are more likely to argue that they need more information on the impact of the law before they can put out detailed next steps.

Still, some broad outlines are taking shape. Here’s the early read on the health care ideas that could influence the White House campaigns in 2016:

Republicans: Repeal, replace and don’t kick people off

Which party has the bigger challenge? It depends how the law is working in 2016, and whether the public is convinced there are more winners or more losers. If it’s sputtering, the Democratic presidential candidates will be as hard pressed to defend the law as the red-state Senate Democrats are now.

Right now, though, it’s the Republicans who have the heavier lift. They have to search for both the right policy — an alternative plan that can appeal to their own supporters and the broader electorate — and a convincing case that Obamacare can still be repealed that late in the game.

The 2014 election “isn’t about [national] public opinion. It’s about West Virginia and Colorado and New Hampshire and North Carolina … New York doesn’t have anything to vote on,” said Robert Blendon, an expert on health care and public opinion at Harvard University.

That will change as soon as the GOP gets past the unique nature of midterm election voters, Blendon said, and has to appeal to a national audience again. “In 2016, the Republicans are going to have to appeal to a wider-range group than 2014. That’s why having something much more comprehensive is really going to be a priority,” he said.

Nearly all of the potential 2016 Republican candidates still say they’re fully committed to repealing Obamacare — including Louisiana Gov. Bobby Jindal, who has already spelled out his repeal plan, and House Budget Committee Chairman Paul Ryan, who just won House passage of another budget that’s built on repeal.

The one who’s taking a softer line right now is Wisconsin Gov. Scott Walker, who’s seen as one of the GOP’s best hopes on other issues crucial to 2016 success. Recently, he has taken the line in interviews that he doesn’t like Obamacare, but it’s the law and he’s not going to sabotage it.

“Obviously, Governor Walker disagrees with the Affordable Care Act. However, it is the law,” said Walker press secretary Laurel Patrick. “As for replacing the ACA, it is a federal issue and outside of Governor Walker’s jurisdiction.”

For the rest, repeal is still the clear goal, which means they’ll need a replacement plan.

Jindal has already released a plan that would repeal Obamacare and replace it with cheaper health insurance options and more targeted help for people with pre-existing conditions. The other two alternatives that are attracting the most attention from conservative health care experts are the plan by three Republican senators — Orrin Hatch, Tom Coburn and Richard Burr — and the one by the 2017 Project, an initiative led by William Kristol that’s trying to develop a GOP agenda with broad appeal.

There are differences, but the three plans share common themes: getting rid of mandates, protecting sick people from rate hikes as long as they’ve gotten health coverage early and stayed insured, relaxing the rules for health insurance and offering a variety of low-cost options, and limiting awards in medical malpractice cases.

And unlike Obamacare, which gives subsidies that vary significantly based on people’s incomes, the GOP plans would give people tax breaks of fixed amounts to keep tighter limits on spending. The Hatch and 2017 Project plans would provide tax credits, which would help low-income people who don’t earn enough to owe taxes. Jindal would use a tax deduction, which doesn’t help low-income people, but he’d give states money to help them subsidize those customers.

Jeffrey Anderson, the executive director of the 2017 Project, doesn’t think a Republican alternative has to set a specific coverage target, but it should set a general goal of increasing health coverage substantially over the old system, not just lowering costs. “I think a proposal that deals with only half of that equation is not going to be a winner,” said Anderson.

The real test, though, will be how the Republican candidates deal with the millions of Americans who will already have Obamacare coverage by then. The Congressional Budget Office predicts that 22 million people could have private health insurance through the law in 2016. The real number might not be that high, but if it’s even close, the GOP candidates will have to have a plan for them.

“They’re going to have to talk about repeal, but they’re going to have to give some assurances that people’s lives aren’t going to be upended again,” said Joe Antos of the American Enterprise Institute.

The potential candidates haven’t really grappled with that part yet. But Capretta said the least disruptive solution probably would be to “grandfather” the Obamacare customers into the new system. Since there’s a lot of turnover in the individual insurance market anyway — people use it for short periods and then get a job with employer coverage, for example — Capretta says they could be allowed to keep their Obamacare coverage until they’re ready to switch plans.

And Anderson says that even if the replacement does change the rules on those customers, the tax credits in the 2017 Project plan would be big enough to cover nearly all of their premiums — and that they might choose to switch to the less expensive plans that would become available anyway.